Rehab Take-home messages: Latissimus Dorsi Reconstruction and Functional Implications of the Shoulder

I turned to the literature and found prominent articles discussing breast reconstruction and giving minimal consequence to shoulder function after resection of the latissimus dorsi muscle. As a physical therapist, this left me in a quandary, “Really? Harvesting a portion of the broadest muscle of the back then threading it through the axilla to recreate the breast mound won’t have an impact on shoulder function or back pain? Impressive!” But, this did not correlate with my clinical findings. Often, scapulohumeral rhythm was altered, range of motion restricted and activities limited due to pain and fatigue. I turned to the literature and found those articles were mostly unsubstantiated. Here is a quick summary of two  systematic reviews published in 2014 addressing what the research really found pertaining to shoulder function after ‘lat flap’ reconstruction:

Patient impressions:

•  Reported incidence of overall functional impairment is 41%.  (8)
• Overhead activities, lifting and pushing objects and high-level activities such as sport and housework were the most cumbersome. (1,7)
• Subjective deficits did not resolve based on length of follow-up. (1)

Strength:

• Greatest deficits are noted with reconstruction on the dominant side. (4)
• Extension of the shoulder is the most common strength deficit followed by adduction then internal rotation. (8)
•   Objective strength deficits typically resolved within a year. (8,9)
•  Rehab should be ordered pro-actively. (4)

Range of Motion:

• Active flexion is the most common restriction followed by abduction. (8)
• Rarely were these restrictions severe. (5,6)
• Restrictions were greatest post-operatively likely due to alterations in shoulder biomechanics, scar formation and post-operative pain.
• Discrepancies were found regarding resolution of range of motion without rehab. (5,8)
• No clinically significant functional morbidity was found when therapy was provided from post-op day 1 (2,3)

Other reported complications that may impact function:

• Taratino, Banic and Fischer noted that capsular contracture was the most significant and recurrent complication in their study (10)
• 50%  reported post-operative numbness and tightness (1)
• Scar tissue adhesions were associated with functional limitations (2,3)

In conclusion, is it feasible to say that the latissimus dorsi muscle bears little consequence to function after reconstruction? I’m going to trust what the researchers performing the systematic reviews say:

• Physicians and researchers Lee and Mun state the following; “over 20 percent of the patients undergoing latissimus dorsi muscle transfer suffered from considerable disability…7 percent of patients changed their job postoperatively. These results suggest that considerable discomfort, even to the extent of limitation on daily activity, can be developed after latissimus dorsi muscle harvest, as opposed to the previous assumption that latissimus dorsi muscle harvest may not lead to serious disability” (8).
•  Smith does give merit to the fact that most strength deficits resolve within 6 to 12 months due to other muscles compensating for function, however, she states “standardization of physical therapy protocols is imperative as it appears to have a measurable positive impact.” Immediately after this statement she remarks that physical therapy is rarely included in the physician’s plan of care (9).

No doubt, it is time we start talking to our surgical oncologists and plastic surgeons.

 

References:

1.       Adams, Jr., W., Lipschitz, A., Ansari, M., Kenkel, J., & Rohrich, R. J. (2004). Functional donor site morbidity following LD muscle flap transfer. Annals of Plastic Surgery, 53(1), 6–11.

2.       de Oliveira, R., Nascimento, S., Derchain, S. & Sarian, L. (2013). Immediate breast reconstruction with a latissimus dorsi flap has no detrimental effects on shoulder motion or postsurgical complications up to 1 year after surgery. Plas­tic and Reconstructive Surgery, 131(5), 673e–680e.

3.       de Oliveira, R. R., Pinto e Silva, M. P., Costa Gurgel, M. S., Pas­tori-Filho, L., & Sarian, L. O. (2010). Immediate breast re­construction with transverse latissimus dorsi flap does not affect the short-term recovery of shoulder range of motion after mastectomy. Annals of Plastic Surgery, 64(4), 402– 408.

4.       Forthomme, B., Heymans, O., Jacquemin, D., Klinkenberg, S., Hoff­mann, S., Grandjean, F. X.,...Croisier, J. L. (2010). Shoulder function after latissimus dorsi transfer in breast reconstruc­tion. Clinical Physiology and Functional Imaging, 30, 406– 412.

5.       Giordano, S., Kääriäinen, M., Alavaikko, J., Kaistila, T. & Kuok­kanen, H. (2011). Latissimus dorsi free flap harvesting may affect the shoulder joint in long run. Scandinavian Journal of Surgery, 100, 202–207.

6.       Hamdi, M., Decorte, T., Demuynck, M., Defrene, B., Fredricks, A., VanMaele, G.,...Monstrey, S. (2008). Shoulder func­tion after harvesting a thoracodorsal artery perforator flap. Plastic and Reconstructive Surgery, 122(4), 1111–1117.

7.       Koh, C. E., & Morrison, W. A. (2009). Functional impairment af­ter latissimus dorsi flap. Australian Journal of Surgery, 79, 42–47. http://dx.doi.org/10.1111/j.1445-2197.2008.04797.x

8.       Lee, K.T., Mun, G.H., (2014).A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer, Plast. Reconstr. Surg. 134: 303.

9.       Smith, S., (2014). Functional morbidity following latissimus dorsi flap breast reconstruction. J Adv Pract Oncol, 5, 181–187.

10.   Tarantino, I., Banic, A., & Fischer, T. (2006). Evaluation of late results in breast reconstruction by latissimus dorsi flap and prosthesis implantation. Plastic and Reconstructive Surgery, 117(5), 1387–1394.